Laserfiche WebLink
SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN 420632, MKT 2368 Date of Testing: 12/23/2020 <br />Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA 95207 <br />Facility Contact: MGR - SATBIR (PTO# N-748) Phone: 209-952-3543 <br />Date Local Agency Was Notified of Testing: 12/15/2020 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Tim Elebeck <br />Credentials l: r CSLB Contractor rv— ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />Licensc Number(s): 8001435 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: FV- Hydrostatic F Vacuum F Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Spill Box # Tank 3 <br />REGULAR - Fill 1 - Direct - <br />Grade level in containment <br />sump <br />Spill Box # Tank 4 <br />PREMIUM - Fill 1- Direct - <br />Grade level in containment <br />sump <br />Spill Box # Tank 5 Diesel - <br />Fill 1 - Direct - Grade level <br />in containment sump <br />Spill Box # <br />Bucket Installation Type: <br />C' Direct Bury <br />C: Contained in Sump <br />C Direct Bury <br />C Contained in Sump <br />r Direct Bury <br />C: Contained in Sump <br />C Direct Bury <br />C Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />15.00 <br />15.00 <br />15.00 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />5 min <br />min <br />Test Start Time (TI): <br />09:10:00 <br />09:10:00 <br />09:10:00 <br />Initial Reading (Rl): <br />14.50 in. 1420 <br />14.25 in. H2O <br />14.50 in. H2O <br />Test End Time(TF): <br />10:10:00 <br />10:10:00 <br />10:10:00 <br />Final Reading (RF): <br />14.50 in. H2O <br />14.25 in. H2O <br />14.50 in. 1420 <br />Test Duration(TF—TI): <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF—RI) : <br />0.00 in. H2O <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/-0.00 <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature <br />Date: 12/23/2020 <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2349621 <br />